Imaging and Intervention in Urinary Tract Infections and Urosepsis

237 Pages·2018·16.24 MB·English

by  Massimo Tonolini (eds.)

Massimo Tonolini
Editor
Imaging and Intervention
in Urinary Tract Infections
and Urosepsis
123
Imaging and Intervention in Urinary
Tract Infections and Urosepsis
Massimo Tonolini
Editor
Imaging and
Intervention in Urinary
Tract Infections and
Urosepsis
Editor
Massimo Tonolini
Department of Radiology
Luigi Sacco Hospital
Milan, Italy
ISBN 978-3-319-68275-4 ISBN 978-3-319-68276-1 (eBook)
https://doi.org/10.1007/978-3-319-68276-1
Library of Congress Control Number: 2017963141
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Contents
Part I Clinicians’ Current Perspectives on Urinary Tract Infections
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Massimo Tonolini
2 Introduction to Urinary Tract Infections: An Overview on
Epidemiology, Risk Factors, Microbiology and
Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Maria Diletta Pezzani and Spinello Antinori
3 Uncomplicated and Complicated Urinary Tract Infections
in Adults: The Infectious Diseases’s Specialist Perspective . . . 17
Spinello Antinori and Maria Diletta Pezzani
4 Perspective from the Urologist . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Ai Ling Loredana Romanò and Antonio M. Granata
5 Perspective from the Andrologist . . . . . . . . . . . . . . . . . . . . . . . . 41
Antonio Maria Granata and Ai Ling Loredana Romanò
6 Nothing Is Simple in Acute Pyelonephritis: A Pragmatic,
Semantic Nephrologist’s View . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Giorgina Barbara Piccoli and Francesca Ragni
Part II Imaging of Upper Urinary Tract Infections
7 Ultrasound of Upper Urinary Tract Infections . . . . . . . . . . . . . 57
Emilio Quaia, Antonio G. Gennari, and Maria A. Cova
8 Cross-Sectional Imaging of Acute Pyeloureteritis and
Pyonephrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Massimo Tonolini
9 CT Imaging and Differential Diagnosis of
Acute Pyelonephritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Adriana Vella and Massimo Tonolini
10 Imaging of Extrarenal Spread, Fistulising and
Atypical Pyelonephritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Massimo Tonolini
v
vi Contents
11 MRI and DW-MRI of Acute Pyelonephritis (APN) . . . . . . . . . . 113
Andrea Veltri, Agostino De Pascale, and Dario Gned
12 Cross-Sectional Imaging of Renal Cyst Infection . . . . . . . . . . . 121
Massimo Tonolini
13 Nuclear Medicine in the Management of Patient with
Kidneys Intracystic Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Daniele Penna, Vincenzo Militano, Vincenzo Arena,
Angelina Cistaro, and Ettore Pelosi
Part III Imaging of Lower Urinary and Male Genital
Tract Infections
14 Ultrasound of Lower Urinary Tract Infections . . . . . . . . . . . . . 145
Emilio Quaia, Antonio G. Gennari, and Maria A. Cova
15 Cross-Sectional Imaging of Urinary Bladder, Prostate
and Seminal Vesicle Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Massimo Tonolini
16 Cross-Sectional Imaging of Urethral, Penile and
Scrotal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Massimo Tonolini
Part IV Miscellaneous Topics
17 Cross-Sectional Imaging of Urosepsis . . . . . . . . . . . . . . . . . . . . . 185
Massimo Tonolini
18 Modern Imaging of Urogenital Tuberculosis . . . . . . . . . . . . . . . 191
Massimo Tonolini
19 Imaging Infections in Transplanted Kidneys . . . . . . . . . . . . . . . 199
Stefano Palmucci, Pietro Valerio Foti,
and Massimiliano Veroux
20 Interventional Radiology for Drainage of Urine . . . . . . . . . . . . 207
Anna Maria Ierardi, Salvatore Alessio Angileri,
Enrico Maria Fumarola, and Gianpaolo Carrafiello
21 Interventional Radiology in the Treatment of
Abscess Collections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Anna Maria Ierardi, Salvatore Alessio Angileri,
Enrico Maria Fumarola, Filippo Piacentino, Natalie Lucchina,
Domenico Laganà, and Gianpaolo Carrafiello
22 Urinary Tract Infections in Infants and Children . . . . . . . . . . . 231
Marcello Napolitano and Anna Ravelli
Part I
Clinicians’ Current Perspectives on Urinary
Tract Infections
1
Introduction
Massimo Tonolini
Arguably representing one of the most prevailing (d) Systemic inflammatory response syndrome
infectious illnesses worldwide, urinary tract with fever or hypothermia, hyperleucocytosis
infections (UTIs) are generally considered trivial or leucopenia, tachycardia and tachypnoea
by most physicians, since the majority of cases (e) Circulatory and organ failure [2]
encountered in the general population are uncom-
plicated occurrences in otherwise healthy young Furthermore, UTIs represent the commonest
women. However, UTIs account for hundreds of (almost 40%) form of hospital-acquired infec-
thousands of outpatient visits and emergency and tions, with bladder catheterisation as the key risk
hospital admissions yearly, resulting in a signifi- factor. The EAU guidelines define complicated
cant clinical and economic burden [1–3]. UTIs (C-UTIs) as those associated with struc-
Indeed, UTIs encompass a heterogeneous tural or functional abnormalities of the genitouri-
spectrum of conditions ranging from asymptom- nary tract, or with the presence of an underlying
atic bacteriuria to mild uncomplicated cystitis, disease that interferes with host defence mecha-
potentially severe pyelonephritis and life- nisms, that result in an increased risk of acquiring
threatening sepsis. Clinical manifestations of infection or failing therapy. The commonest con-
UTIs may be limited or overlap with pre-existing ditions predisposing patients to either acquiring
complaints from chronic urinary tract dysfunc- infection or experiencing a more severe outcome
tion. According to the European Association of are categorized with the mnemonic RENUC and
Urology (EAU) guidelines, severity of UTIs summarized in Table 1.1 [2].
should be graded clinically as: Traditionally, the vast majority of ascending
UTIs were considered uncomplicated and did not
(a) Asymptomatic routinely require imaging investigation, particu-
(b) Causing local symptoms such as dysuria, uri- larly in women of childbearing age. During my
nary frequency, urgency, supra- or retropubic years as a resident in diagnostic imaging at the
pain or bladder tenderness San Paolo Hospital in Milan (Italy) in the late
(c) Causing general symptoms including fever, 1990s, radiologists were only occasionally
flank pain, nausea and vomiting requested to investigate patients with suspected
UTIs, in the vast majority of cases to exclude uri-
nary obstruction with ultrasound and occasion-
M. Tonolini ally to study sequelae after acute pyelonephritis
Radiology Department, “Luigi Sacco” University (APN) with intravenous pyelography. In fact,
Hospital, Via G.B. Grassi 74, Milan 20157, Italy
until a few years ago, the diagnosis of UTI was
e-mail: [email protected]
© Springer International Publishing AG 2018 3
M. Tonolini (ed.), Imaging and Intervention in Urinary Tract Infections and Urosepsis,
https://doi.org/10.1007/978-3-319-68276-1_1
4 M. Tonolini
Table 1.1 Risk factors for acquiring urinary tract infection, developing complications and/or failing treatment (mne-
monic RENUC) (Reproduced from Open Access Ref. no.[17], partially adapted from Ref.no. [2])
Type Risk factors Risk of more severe outcome
Recurrent Sexual behaviour No
Contraceptive devices
Postmenopausal hormonal deficiency
Controlled diabetes mellitus
Extra-urogenital Pregnancy Yes
Male gender
Badly controlled diabetes
Immunosuppression including HIV, uraemia,
transplant recipients, on corticosteroids,
chemotherapy or immunosuppressants
Connective tissue disease
Nephropathy Impaired renal function Yes
Polycystic kidney
Urological Obstructive uropathy, e.g. congenital, Yes
lithiasis, stricture, tumour
Short-term catheterisation
Neurogenic bladder
Urological surgery or instrumentation
Permanent catheter or non- Long-term catheter Yes
resolvable urological risk factors Non-resolvable obstruction
Badly controlled neurogenic bladder
primarily clinical and based upon a combination tions and on the increasingly concerning issue of
of clinical symptoms and signs plus consistent bacterial resistance to antibiotics.
urinalysis and biochemical changes. At those Furthermore, growing evidence has accumu-
days, imaging was reserved for: lated on the potential detrimental effect of UTI on
renal function, which results from a combination
(a) Patients with unusually severe symptoms, in of direct cellular injury and indirect effects of
which differentiation from renal colic or inflammatory mediators. In patients with pre-
other acute abdominal disorders was required existing normal renal anatomy and function, renal
(b) Patients with recurrent UTIs, to look for scarring has been reported to develop in up to
underlying treatable structural or functional 55% of patients after APN. Patients with chronic
abnormalities kidney disease or diabetes are particularly prone
(c) Patients with predisposing conditions to to progression of renal infection and deterioration
C-UTIs such as diabetes, immunosuppres- of function, with the latter becoming permanent
sion, etc. in the majority (77%) of cases [2, 7].
(d) Patients who failed to respond to conven- A highly prevalent disease, APN, reaches an
tional antibiotic therapy within 72 h [4–6] annual incidence of 250,000 cases and yearly
accounts for over 100,000 hospitalizations in the
Meanwhile, during the last decade, the scenario USA, with a non-negligible mean duration
of UTI has changed, as discussed in the first sec- (11 days). However, there is no consensus on the
tion of this book which includes current clinical definition of APN, which – until a few years ago –
perspectives from prominent urologists, nephrolo- was almost invariably diagnosed clinically on the
gists and specialists in infectious diseases. In these basis of fever, flank pain and tenderness, signs and
chapters emphasis is placed on high-risk popula- symptoms of lower UTI, accompanied by leucocy-
1 Introduction 5
tosis, increased acute phase reactants, haematuria, a consistent basis for correct therapeutic choice.
bacteriuria and positive urine culture [2]. Emphasis is placed on the increasingly imple-
However, several recent studies-particularly mented diffusion-weighted (DW)-MRI sequences
those by G.B. Piccoli and C. Rollino-reported and apparent diffusion coefficient (ADC) maps
that APN presents with full-blown features in to differentiate between spared parenchyma,
only a minority of patients. The correlation nephritis and abscesses, particularly in children
between clinical presentation, entity of abnormal and patients with contraindication to intravenous
biochemistry (C-reactive protein and leukocyte contrast [12–16].
count) and extent of renal lesion in APN is often The third section of this volume reviews the
very limited: oligosymptomatic manifestations imaging appearances of UTIs involving the pros-
may correspond to multifocal lesion or abscesses, tate, seminal vesicles, urethra, perineum, penis
which require hospitalization and long-term ther- and scrotum. Despite improved standards of
apy, and are associated with higher risk of devel- care, “lower” UTIs are increasingly observed in
oping renal scarring. Furthermore urine, blood patients with risk factors such as neurogenic dys-
cultures and both are positive only in 23.5–40%, function, bladder outlet obstruction, obstructive
15.8–30% and 7.6% of cases, respectively, uropathy, urologic instrumentation or indwelling
mostly because of previous empirical antibiotic stent, urinary tract postsurgical modifications,
therapies administered in the outpatient setting chemotherapy or irradiation, renal dysfunction,
[8–10]. Conversely, a few other studies showed diabetes and immunodeficiency [3]. With ade-
that some early available clinical predictors, quate technique and awareness of consistent find-
namely, diabetes, hypotension, high leucocytosis ings, CT and MRI comprehensively assess the
and acute renal failure, may identify almost all lower genitourinary structures and disorders and
patients with moderate (except for some cases of increasingly provide accurate detection of pres-
microabscesses) and severe APN [11]. ence and extent of infectious changes, of pos-
Since choosing the most appropriate treatment sible complications, and assist in the differential
relies on severity assessment, nowadays there is a diagnosis [17].
growing need for “pathological” diagnosis of Furthermore, in our experience imaging signs
APN by radiological demonstration of parenchy- of clinically unsuspected C-UTI may be inci-
mal involvement; this is particularly true for dentally detected in imaging studies performed
abscessual forms, which require longer intensive to investigate other conditions such as urolithia-
in-hospital intravenous antibiotic therapy and are sis, renal colic, gynaecologic pain or unspecific
associated with higher risk of developing renal abdominal pain [17]. Cross-sectional imaging is
scars [2]. paramount in the triage of sepsis, to confirm an
Meanwhile, state-of-the-art multidetector underlying urological cause: albeit less severe
computed tomography (CT) and magnetic reso- compared to other sources, urosepsis remains
nance imaging (MRI) reached extremely high associated with 20–40% mortality [2, 7].
accuracy in delineating the nature and extent of Other dedicated chapters, respectively, review:
APN changes and consistently depict complica-
tions such as abscess and obstruction. Emergency – The role of nuclear medicine (specifically
physicians increasingly request early imaging of with positron emission tomography) in the
suspected APN, which is preferably carried out detection and follow-up of infections in poly-
with MRI particularly in young patients and cystic kidneys
childbearing age women. Therefore, the fol- – The imaging of urogenital tuberculosis in the
lowing ample radiological section of this book current CT era
reviews the role, techniques and imaging appear- – The imaging of UTI in patients with renal
ances of upper UTIs using ultrasound and con- transplant
trast-enhanced ultrasound (CEUS), multidetector – The expanding role and possibilities of inter-
CT and MRI to assess severity and thus provide ventional radiology in the treatment of severe